The undersigned physician organizations welcome the Trump Administration’s emphasis on reducing regulatory burdens. Congress recognized when it passed the Medicare Access and CHIP Reauthorization Act (MACRA) in an overwhelming bipartisan vote that the existing Medicare value-based purchasing programs affecting physicians—Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-based payment modifier (VM–needed to be streamlined and aligned. As the Centers for Medicare & Medicaid Services (CMS) implemented MACRA through the Quality Payment Program (QPP), we were grateful the agency recognized there were a number of challenges with the requirements of MU, PQRS, and VM. Consequently, we urge the Administration to take a series of steps to address these same challenges in MU, PQRS, and VM prior to their replacement by MACRA and minimize the penalties assessed for physicians who tried to participate in these programs. Clearly this would send a strong message to the physician community about the extensive regulations with which physicians have been dealing and the Administration’s commitment to reduce the burden.

As directed by the 21st Century Cures Act, CMS must establish a strategy to relieve the electronic health record (EHR) documentation burden. To fulfill this legislative directive, we urge CMS to establish a new “Administrative Burden” category of hardship exemption for the 2016 MU performance year. Eligible providers should not be penalized for focusing on providing quality patient care rather than the arbitrary “check the box” requirements of MU. Creating an administrative burden hardship exemption would provide immediate relief for those impacted by the programs that predate MACRA.

We also urge CMS to create a hardship exemption for physicians who attempted to report PQRS in 2016 but were unsuccessful due to the complexity of the reporting requirements and the significant number of measures that were required. The AMA has heard from many physicians who tried to successfully report PQRS 2016, but were unable to find nine measures that were applicable and meaningful for their specialty. Physicians also reported difficulties with the requirements that one measure had to be a cross-cutting measure, and the nine measures had to cover three National Quality Strategy Domains. Therefore, we recommend that CMS create a hardship exemption that would allow physicians who successfully reported on any number of PQRS measures in 2016 to avoid the two percent penalty in 2018.

CMS recognized the difficulty of the reporting requirements and lack of applicable measures by reducing the requirements in the QPP to six measures and eliminating the domain and crosscutting measure requirements.

In addition, CMS should take a number of steps to protect physicians from additional penalties of up to four percent under the VM. As a starting point, any physician who avoided the PQRS penalty in 2018 should be exempt from any VM penalties as well. These physicians would then all be eligible to participate in a voluntary quality-tiering program where positive, negative, or neutral payment adjustments would be distributed based on a comparison of performance on the applicable VM cost and quality measures for all tiering-eligible physicians, including those who chose not to enter the tiering process. In other words, physicians who met the nine-measure PQRS submission requirements or were eligible for a PQRS hardship exemption would not be penalized under the VM unless they voluntarily chose to compete and then scored poorly in the tiering process. Payment adjustments would be budget neutral, with bonuses for high performers financed by penalties for those who did not attempt to participate in PQRS or performed poorly in the tiering process. Practices of all sizes would receive a performance feedback report so that they could gain a better understanding of Medicare cost and quality measures and identify areas where their performance could be improved.

As indicated in the MACRA law and final regulations, policymakers in Congress and the Administration clearly understand that fair and accurate measurement of physicians’ performance will not be possible until better tools become available. We are extremely appreciative of the efforts CMS has made to recognize and compensate for methodological shortcomings in MU, PQRS, and VM. We believe that the policies outlined above are consistent with the direction CMS is taking as we go forward with MACRA. We also believe the steps we have outlined are in keeping with President Trump’s efforts to reduce regulatory burden.

We recognize that there might be other ways to achieve the same goal. We are open to discussing other options.

Sincerely,

American Medical Association Advocacy Council of the ACAAI American Academy of Allergy, Asthma & Immunology American Academy of Family Physicians American Academy of Hospice and Palliative Medicine American Academy of Neurology American Academy of Otolaryngology-Head and Neck Surgery American Academy of Physical Medicine and Rehabilitation American Association of Hip and Knee Surgeons American Association of Neurological Surgeons American Association of Neuromuscular & Electrodiagnostic Medicine American College of Allergy, Asthma and Immunology American College of Emergency Physicians American College of Gastroenterology American College of Mohs Surgery American College of Physicians American College of Rheumatology American College of Surgeons American Congress of Obstetricians and Gynecologists American Gastroenterological Association American Osteopathic Association American Psychiatric Association American Society for Radiation Oncology American Society for Surgery of the Hand American Society of Anesthesiologists American Society of Cataract and Refractive Surgery American Society of Clinical Oncology American Society of Dermatopathology American Society of Neuroradiology American Society of Plastic Surgeons American Society of Retina Specialists American Society of Transplant Surgeons American Urological Association Congress of Neurological Surgeons Endocrine Society Medical Group Management Association North American Spine Society Obesity Medicine Association Renal Physicians Association Society for Cardiovascular Angiography and Interventions Society of Critical Care Medicine Society of Hospital Medicine The Society of Thoracic Surgeons Medical Association of the State of Alabama Alaska State Medical Association Arizona Medical Association Arkansas Medical Society California Medical Association Colorado Medical Society Connecticut State Medical Society Medical Society of Delaware Medical Society of the District of Columbia Florida Medical Association Inc Medical Association of Georgia Hawaii Medical Association Idaho Medical Association Illinois State Medical Society Iowa Medical Society Kentucky Medical Association Louisiana State Medical Society Maine Medical Association MedChi, The Maryland State Medical Society Massachusetts Medical Society Michigan State Medical Society Minnesota Medical Association Mississippi State Medical Association Missouri State Medical Association Montana Medical Association Nebraska Medical Association Nevada State Medical Association New Hampshire Medical Society New Mexico Medical Society Medical Society of the State of New York North Carolina Medical Society North Dakota Medical Association Ohio State Medical Association Oklahoma State Medical Association Oregon Medical Association Pennsylvania Medical Society Rhode Island Medical Society South Dakota State Medical Association Tennessee Medical Association Texas Medical Association Vermont Medical Society Medical Society of Virginia Wisconsin Medical Society Wyoming Medical Society